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Saturday, May 18, 2013

Who Should Determine “Medical Necessity”?

The following is a guest post.These days, there is a lot of
talk about expanding scopes of practice for the group of folks who used to be
called “physician extenders” and then “midlevel providers” and more recently
“non-physician providers,” many of whom are now getting degrees with the title
“doctor” incorporated. While it seems to
vary, these folks may include nurses, physician assistants (one day to be called “physician associates” perhaps), pharmacists, and more. Lots of forums are discussing whether folks
who are not doctors should be calling themselves “doctor” or whether they
should be expanding their scope of practice via legislative rather than
educational means. But a recent personal anecdote has made me wonder about a
slightly different question: should non-physicians be able to certify “medical
necessity”?

Two family members are covered under the same
insurance policy.

He has had a history of knee injury, related surgery,
and subsequent successful rehabilitation. He recently ran a marathon, and now
has new knee pain that has persisted after 8 weeks of conservative therapy at
home. After a long wait for an appointment slot, he finally sees an orthopedic
surgeon with knee expertise. The doctor recommends an MRI to evaluate the
nature of his ongoing pain.

She has chronic back pain that seems to be acting up,
and sees a chiropractor mostly out of convenience, since the office is in the
strip-mall near her home and he can see her anytime as a walk-in. After just two
sessions with the chiropractor, he suggests an MRI, since she isn’t responding
as well as he had expected to the adjustments.

The insurance company immediately approves the
chiropractor’s MRI, but denies the orthopedic surgeon’s. The request was appealed, and again denied, on
the grounds that it was not medically necessary. The insurance company issued a
requirement that the physician first document the patient’s participation in a physical
therapist’s prescribed self-care routine for at least 6 more weeks (recall that
the patient has essentially already done this for 8 weeks, having had formal PT
for the knee in the past, and familiar with the appropriate self-care, but this
did not satisfy the payer). Only after jumping through this hoop may the doctor
meet the standard of “medical necessity” to obtain the MRI.

I suppose it's OK for nonphysicians to certify medical necessity...after all, haven't the people on the other end of the phone (the fine folks working for the insurance company) been doing this for quite some time?

The example listed verifies something I've said for a long time. On any given day, you can call a payer and get one answer, then call the next day with the same question and get an entirely different answer. I wonder, did the orthopedist ask to speak to a medical director? Although I don't feel that should be necessary, I have found that when I have been put in touch with them, my requests are approved, especially if I have clinical information to support it.

There is some cognitive dissonance among physicians on this matter. If there is EBM material against a certain intervention, should a physician insist on his superior judgement? Why shouldn't a third party (e.g. the insurer) step in?

Most physicians (esp. surgeons) think they are above average. For instance, a recent NEJM (or maybe JAMA) review concluded that results of robotic prostatectomies are no better than any other method. Multiple urologists jumped up in the national media to claim that "But, but, in *my* hands, robotic is much much better."

What a joke!! As is well known, MRIs are most often a waste of money and resources in chronic LBP (excluding the recent work on Ab's for patients with Mobic type I changes - maybe that will change one day). How will it change a chiropractor's management anyway? Surely a plain XR is good enough to show the subluxations anyway?? ;) I am baffled by the US medical system..

Anonymous, as long as "medical necessity" rulings are reasonable, I have no problem with them. The post is about the absurdity of an orthopedist being denied an MRI for 6 weeks while a chiropractor can order one any time.

I think it is about time I start letting the malpractice lawyer world know that I am now available to be an expert witness against all the Noctors, PAs, etc. who are stepping beyond their bounds and screwing up.I think the standard of care for any of them should be the standard of care a prudent physician would do.I bet I could make a killing.

Rugger, you are right. The whole area of APRNs, PAs, CRNAs and so-called "noctors" (nurses with doctorates in nursing) are fertile fields for the plaintiff's bar. There probably is money to be made as an expert witness.

artiger - Chiropractic education does include retrieval and interpretation of images (almost exclusively x-ray, but does include things like certain tumors, herniations, and syringomyelia on axial imaging). Understandably, most chiropractors don't have their own MRI or CT in office, but many have their own x-ray equipment and are within their legal bounds to take and interpret their own images. The program I'm most familiar with has 5 semesters of radiology training. Clearly, this is nowhere near the level of training of 4 dedicated years of radiology residency that medical doctors have, but it seems to be adequate for outpatient chiropractic practice.

Araikwao - An MRI would most likely change the treatment/referral plan of the chiropractor if it revealed a significant herniation or other space occupying lesion.

artiger - I should have added that while chiropractors are within their bounds to interpret the images and bill for it, some don't do it because it elevates them to the level of liability of a specialist.